Acute coronary syndromes in young women - the scale of the problem and the associated risks

A young woman with acute coronary syndrome and antiphospholipid syndrome. Is it the antiphospholipid syndrome or COVID-19 vaccination or classical risk as the risk factor? a case report

BACKGROUND

Acute coronary syndrome (ACS) in young women is poorly understood due to underdiagnosis and undertreatment. One of the possible risk factors for ACS in young women is antiphospholipid syndrome (APS). Coronavirus disease 2019 (COVID-19) vaccination also emerged as one of the possible risk factors for ACS during the COVID-19 pandemic.

CASE PRESENTATION

Our patient, a 39-year-old Batak woman with dyslipidemia and family history of cardiovascular disease, experienced chest pain slightly improved at rest accompanied by autonomic symptoms. She was diagnosed with non-ST-elevation myocardial infarction (NSTEMI) based on her clinical features, dynamic electrocardiogram changes, troponin elevation, and multislice computed tomography angiography confirmed with diagnostic catheterization. The patient was managed by percutaneous coronary intervention with implantation of drug-eluting stents. On follow-up, the patient was diagnosed with APS based on history of preeclampsia with severe features in the first and third pregnancy, spontaneous abortion in the second pregnancy, history of transient ischemic attack, moderately positive lupus anticoagulant on two occasions with an interval of 12 weeks, and ACS. Further investigation revealed a history of COVID-19 vaccination with Sinovac four and six weeks before presentation. The patient was recommended for lifelong warfarin and short-term dual antiplatelet (aspirin and ticagrelor).

CONCLUSIONS

Young women are not completely immune to ACS as evident in this case of ACS in a young woman with classical risk factors (dyslipidemia and family history of cardiovascular disease) and APS. Further studies are required to fill the knowledge gap on whether COVID-19 vaccination had any contribution to the ACS in the young woman.

Acute Myocardial Infarction in a 17-year-old High-school Girl

We report an unusual case of acute myocardial infarction in a high school girl. The patient was 17 years of age and had multiple coronary risk factors, including marked obesity with a body mass index (BMI) of 42.7 kg/m², dyslipidemia and glucose intolerance. She had been an on and off smoker since she was 13 years of age. Due to the recent Westernization of the lifestyle, the prevalence of metabolic syndrome in the young generation has been increasing in Japan. Cardiovascular disease based on lifestyle-related diseases may become more common in young people.

Analysis of traditional and emerging risk factors in premenopausal women with coronary artery disease: A pilot-scale study from North India

Premenopausal women are known to have less heart disease than their menopausal counterparts and men. However, there is a rising prevalence of coronary artery disease (CAD) in premenopausal females, which necessitates determination of risk factors that negate the effects of hormonal protection. There are few studies describing the prevalence of traditional and emerging risk factors in premenopausal women with CAD. Thus, our objective was to explore the prevalence of traditional and emerging risk factors and features of coronary lesions in premenopausal women with CAD in an Indian population. Forty premenopausal female patients with angiographically proven CAD and undergoing treatment with conventional therapies and 40 age-matched premenopausal females without any evidence of CAD were enrolled. Premenopausal females with CAD most commonly had the single-vessel CAD and the left anterior descending artery was most commonly involved. The prevalence of hypertension, diabetes, obesity, metabolic syndrome, family history of CAD and 10-year risk score was higher in premenopausal females with CAD than controls. Even after treatment with conventional therapies, premenopausal women with CAD had dyslipidemia and significantly elevated levels of emerging risk factors such as ApoB, ApoB/ApoA1 ratio, hsCRP, lipoprotein (a), uric acid, T4, fibrinogen, and total leukocyte count as compared to controls (p < 0.05). Further, they had significantly lower levels of HDL-C, and Apolipoprotein A1 and T3 which are protective markers for vascular risk. Multivariate regression analysis demonstrated that low levels of Apo A1 and high levels of fibrinogen, hsCRP and TG drive the vascular risk, and therefore these factors should be considered as candidates for better diagnosis, early detection, and intervention of CAD in premenopausal women.

Clopidogrel Improves Skin Microcirculatory Endothelial Function in Persons With Heightened Platelet Aggregation

Background

Platelet activation can lead to enhanced oxidative stress, inflammatory response, and endothelial dysfunction. To quantify the effects of platelet inhibition on endothelial function, we assessed platelet activity of healthy persons before and after clopidogrel administration and evaluated its effects on endothelial function. We hypothesized that clopidogrel, by attenuating platelet activity, would result in enhanced endothelial function.

Methods and Results

Microcirculatory endothelial function was quantified by laser Doppler flowmetry (LDF) mediated by thermal hyperemia (TH) and postocclusive reactive hyperemia, respectively, in 287 and 241 relatively healthy and homogenous Old Order Amish persons. LDF and platelet aggregation measures were obtained at baseline and after 7 days of clopidogrel administration. Our primary outcome was percentage change in post‐ versus preclopidogrel LDF measures. Preclopidogrel TH‐LDF and platelet aggregation were higher in women than in men (P<0.001). Clopidogrel administration was associated with ≈2‐fold higher percentage change in TH‐LDF in participants with high versus low baseline platelet aggregation (39.4±10.1% versus 17.4±5.6%, P=0.03). Clopidogrel also increased absolute TH‐LDF measures in persons with high platelet aggregation (1757±766 to 2154±1055, P=0.03), with a more prominent effect in women (1909±846 to 2518±1048, P=0.001). There was no evidence that clopidogrel influenced postocclusive reactive hyperemia LDF measures.

Conclusions

The administration of clopidogrel in healthy persons with high baseline platelet aggregation results in improved TH‐induced microcirculatory endothelial function. These data suggest that clopidogrel may have a beneficial effect on microcirculatory endothelial function, presumably through antiplatelet activity, and may confer additional vascular benefits.

Clinical Trial Registration

URL: https://www.clinicaltrials.gov. Unique identifier: NCT00799396.

The Associations Between the Polymorphisms of Vitamin D Receptor and Coronary Artery Disease: A Systematic Review and Meta-Analysis

Vitamin D receptor (VDR) polymorphisms were indicated to be associated with coronary artery disease (CAD); however, published studies reported inconsistent results.The aim of this meta-analysis is to reach a more accurate estimation of the relationship between VDR genetic polymorphisms and CAD risk.Eligible studies were retrieved by searching PubMed, Embase, VIP, Wanfang and China National Knowledge Infrastructure databases. Included and excluded criteria were formulated. The case group was patients with CAD, and the control group was healthy subjects. Summary odds ratios (ORs) and 95% confidence intervals (CIs) were used to evaluate VDR polymorphisms associations with CAD risk. Heterogeneity was evaluated by Q statistic and I statistic.Seven studies of a total of 2306 CAD patients and 4151 control subjects met the inclusion criteria. The pooled results from Taq1 showed increased risk in allelic model (OR = 1.14, 95% CI = 1.02-1.28), dominant model (OR = 1.21, 95% CI = 1.02-1.43), heterozygote model (OR = 1.19, 95% CI = 1.00-1.1.42), and homozygote model (OR = 1.27, 95% CI = 1.01-1.61). Besides, Fok1 T > C showed decreased risk in allelic model (OR = 0.81, 95% CI = 0.65-1.00) and Fok1 A > G also showed decreased risk in allelic model (OR = 0.67, 95% CI = 0.45-1.00) and recessive model (OR = 0.55, 95% CI = 0.31-0.97). In Caucasian subgroup, Bsm1showed increased risk in allelic model (OR = 1.23, 95% CI = 1.02-1.47), heterozygote model (OR = 1.20, 95% CI = 1.00-1.44), and homozygote model (OR = 1.22, 95% CI = 1.02-1.45). In CAD patients with type 2 diabetes mellitus (T2DM), Apa1showed a decreased risk in heterozygote model (OR = 0.80, 95% CI = 0.66-0.98); however, increased risk in recessive model (OR = 5.00, 95% CI = 2.74-9.13) was discovered in CAD patients without T2DM.The Fok1 polymorphism may play a protective role in CAD, and the possible protective role in Apa1 CA genotype in CAD patients with T2DM needs further studies. The Taq1 polymorphism is found to be associated with a significant increase in CAD risk based on our analysis; moreover, increased risk in Apa1 polymorphism in CAD patients without T2DM and Bsm1 polymorphism in Caucasian group is also detected.